APPENDIX F Session A Facilitative Supervision for Quality Improvement Curriculum 2008

1. Integrating Best Practicesfor Performance Improvement, Quality Improvement, and Participatory Learning and Action to Improve Health Services APPENDIX FSession A Facilitative Supervision for Quality Improvement Curriculum 2008

2. Resources: Guidance for Program Staff Integrating Best Practices for Performance Improvement (PI), Quality Improvement (QI), and Participatory Learning and Action (PLA) to Improve Health Services

3. What Are These Approaches? • Performance improvement (PI) • Quality improvement (QI) • Participatory learning and action (PLA)

4. Performance Improvement Process Consultant Factors—Role Assumed, Communication Skills Obtain and Maintain Stakeholder Agreement and Participation in the PI Process PNA Consider Institutional Context Mission Goals Strategies Culture Client and Community Perspectives Define Desired Performance Strengths to Build on and Performance Gaps Find Root Causes Why does the performance gap exist? Select Interventions What can be doneto close the performance gap? ImplementIntervention Describe Actual Performance Monitor and Evaluate Performance

5. Performance Factors • Job expectations • Performance feedback • Physical environment and tools • Motivation • Skills and knowledge to do the job

6. PI Tools and Interventions (1) • PNA stakeholders meeting • Typical tools to define actual performance: • Interviews with providers/staff/supervisors • Observation of client-provider interaction • Facility audit/assessment • Review of service statistics • Client interviews • Group discussions in the community

7. PI Tools and Interventions (2) • Interventions range widely in size and scale, based on the needs identified. The facilitator helps participants to diagnose gaps in performance and identify appropriate interventions. Interventions focus on strengthening the performance factors and may come from any source of knowledge, experience, and best practices.

8. PI Tools and Interventions (3) • Intervention examples: • Training • Supervision strengthening • Marketing/communication • Community mobilization

9. Quality Improvement Process Best practice 1. Information gathering and root cause analysis 2. Action planning and prioritization Actual practice 4. Follow-up and evaluation 3. Implementation

10. Underlying Principles • A customer mindset • Staff involvement and ownership • Focus on systems and processes • Cost-consciousness and efficiency • Continuous quality improvement • Staff development and capacity building

11. Rights of clients Information Access to services Informed choice Safe services Privacy and confidentiality Dignity, comfort, and expression of opinion Continuity of care Staff needs Facilitative supervision and management Information, training, and development Supplies, equipment, and infrastructure Clients’ Rights and Staff Needs

12. QI Approaches Facilitative supervision Whole-site training(including Inreach) QI Tools COPE® Community COPE Quality Measuring Tool Cost Analysis Tool Medical Monitoring EngenderHealth’s QI Package

13. Facilitative Supervision • Facilitative supervision is a system of management whereby supervisors at all levels in an institution focus on the needs of the staff they oversee. • The most important role of the facilitative supervisor is to enable staff to: • Manage the QI and PI process • Meet the needs of clients • Implement institutional goals

14. When Training Is the Answer: Whole-Site Training (WST) WST is an approach to training that: • Meets the learning needs of all staff at a service-delivery site • Views a service-delivery site as a system and treats staff as members of the team that makes the system work • Makes training more cost-efficient

15. Inreach Inreach involves orienting and informing staff within the facility about available services. It: • Reduces missed opportunities to provide needed services to clients • Establishes linkages and referrals between departments • Ensures that signs and information for clients are available throughout the facility

16. COPE: A Continuous QI Process • Client- • Oriented, • Provider- • Efficient services

17. COPE Tools • Self-assessment guides, including record-review checklist • Client interviews • Client-flow analysis (CFA) • Action plan

18. COPEHandbook COPEToolbooks: Family planning Reproductive health Child health Maternal health Community involvement Adolescent reproductive health Emergency obstetric care PMTCT services Cervical cancer HIV treatment and care HIV testing and counseling The COPE Toolbox

19. Medical Monitoring—What Is It? Medical monitoring: • Is an objective assessment of actual services, to identify and close gaps between actual and desired practices. The two main components to assess are “readiness” of the facility and ”processes of care” • Ensures that clinical standards, norms, and policies are implemented properly

20. Community COPE • Based on experience in several countries (Bangladesh, Kenya, Nepal, and others) • Some tools adapted from Participatory Learning and Action (PLA) • Used after sites are experienced with COPE • Helps establish links between site and community • Uses combined strength to improve services

21. Cost-Analysis Tool • Measures direct costs of providing services • Cost of service providers’ time • Cost of supplies used • Can be used to • Set user fees for different services • Negotiate subsidies • Compare costs of changes in type of procedure and provider (Decisions must be based on best medical practice, client’s situation, etc.)

22. The QMT: Is based on COPE Measures progress in improving quality over time Quantifies the results of efforts to improve quality Encourages staff participation in monitoring Quality Measuring Tool (QMT)

23. Quality of Care at a Site (1996-1998) Clients' Rights and Staff's Needs

24. Information Gathering Record/ case review Data review CFA Observation of services Client interview Staff interview COPE® Facility audit INFO Quality Measuring Tool Community assessment Cost analysis Identify gap between actual practice and best practice INFO PNA

25. PLA Process • 1. Explore issues: • Gather information • Analyze and prioritize problems • 2. Build support: • Orientation to project objective and process • Identify community participants • Create linkages w/other stakeholders Apply relevant PLA tools in all steps • 4. Monitor progress: • Were actions completed? • Were results satisfactory? • Are there new issues • to address? 3. Develop community action plans: Solutions may be implemented by community members and health workers

26. PLA vs. PRA • Participatory learning and action (PLA): • Aims to empower communities to undertake ongoing self-development • Participatory methods used in assessment, project design, implementation, monitoring, and evaluation • Requires ongoing commitment over many months or years • Participatory Rural Appraisal (PRA): • Aims to extract information from communities for assessments, usually to inform project design • Can be done in only a few days per community

27. Social mapping FP or sex census mapping Transect walks Venn diagrams Matrix ranking Trend analysis (RH lifeline) Ranking and scoring Causal-impact analysis Pocket chart Three-pile sorting Picture stories/cartooning Drama and role plays Flexi-flans as creative materials Unserialized posters Carts and rocks Critical incident analysis Two circles exercise Semi-structured interviews Focus-group discussions Case studies, stories, portraits PLA Tools for RH Issues

28. Interventions Based on PLA • PLA-based interventions range widely, depending on the issues addressed, the resources available, the level of participation, and who participates. • Some are implemented by community members • Some are implemented by health workers or outside agency • At the highest level of participation, communities set their own agenda and mobilize to carry it out in the absence of outsiders, initiators, and facilitators. They may identify issues beyond health.

29. What Makes All of These Approaches “Best Practices”? They are: • Evidence-based • Replicable • Transferable • Sustainable • Widely recognized and applied in the field of international health (e.g., USAID’s MAQ Initiative, WHO’s Implementing Best Practices Initiative, Advance Africa’s Compendium of Best Practices)

30. Why Integrate These Approaches? • ACQUIRE partners bring proven, effective approaches to improve provider performance and quality of services. • The approaches are mutually reinforcing. • Together, they promote the ACQUIRE Project results: • Access • Quality • Use of RH services

31. What Are the Similarities in These Approaches? • All are participatory. • All rely on a step-by-step process to identify gaps and solutions. • All include root-cause analysis of gaps. • All include stakeholder involvement and empowerment.

32. What Are the Differences in These Approaches? (1) • PI focuses on provider performance and provider perspective • QI focuses on clients’ rights and staff needs and the client perspective

33. What Are the Differences in These Approaches? (2) • Both PLA and Community COPEemphasize the community perspective, but: • Community COPEfocuses on involving communities in improving facility-based health care • PLA includes more tools and addresses community empowerment more broadly around health and/or other issues • Under ACQUIRE, PLA methods have also been applied to tailor information and marketing materials and referral systems based on community perceptions of underutilized methods

34. What Do We Recommend? (1) • PI is most appropriate at national, regional, and district levels, but can be applied to specific cadres of providers. • EngenderHealth’s QI tools address multiple levels, with a focus on the facility level. • Community COPE and PLA are complementary. • e.g., use any of the PLA tools when doing Community COPE

35. What Do We Recommend? (2) • Use PIA to identify needs at higher program levels. • When implementing any of the approaches, at the data-gathering stage, consider adapting tools from any of the other approaches. • In a PNA, consider using QMT, the COPE client interview guide, or any PLA tool. • Within PLA, consider using Community COPE tools. • Apply QI and PLA as ongoing processes to improve quality and address the needs identified.

36. Complementary Use of PI, QI, and PLA Beginning at a National Programming Level 2. National Stakeholder Agreement Meeting 1. MOH wants to explore performance problems 3. PNA conducted in regions Stakeholders analyze gaps, select interventions DESIGN, IMPLEMENT, MONITOR, EVALUATE Develop, disseminate job expectations, standards Whole-site training: Ex: Orient all staff on IP, CTU Facilitative supervision forQI training For regional and district supervisors COPE®at facility PLA

37. Complementary Use of PI, QI, and PLA Beginning at the Community Level Ongoing community health and development actions, based on PLA activities Facilitative supervision implemented at the community health facilities COPE® implemented in facilities Plan: To do a PNA to agree on and develop appropriate interventions to strengthen and improve access to IUD services • Results: • Numerous improvements in participating facilities • Continuous QI in participating facilities • Increased IUD utilization (Expected Result)